1114978731 NPI number — FREESTATE MEDICAL SUPPLY, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114978731 NPI number — FREESTATE MEDICAL SUPPLY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FREESTATE MEDICAL SUPPLY, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114978731
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/17/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 674553
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48267-4553
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-440-9320
Provider Business Mailing Address Fax Number:
877-785-7396

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7830 BACKLICK RD STE 202
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22150-2205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-440-9320
Provider Business Practice Location Address Fax Number:
877-785-7396
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VESTAL
Authorized Official First Name:
EMILY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT AND DIRECTOR
Authorized Official Telephone Number:
866-897-8588

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1114978731 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 012424900 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 02917802 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 345902100 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 55790700 , issued by the state of ( DC ) . This identifiers is of the category "MEDICAID".




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